The General Internist.

Although general internists recognize the medical complications arising from alcohol abuse, they may be less familiar with its social and psychological consequences or with methods for its treatment. Because internists are the only physicians some patients see, they must be prepared to diagnose and take part in the treatment of alcohol problems.

1 Although the terms "alcoholism" and "alcohol abuse" usually are not interchangeable, they are used here and throughout the article as general terms meaning chronic overconsumption of alcohol.

EPIDEMIOLOGY OF ALCOHOLISM
Although communitybased surveys have found that the prevalence of alcoholism in the general U.S. population can be as high as 12 percent, its prevalence is higher in populations of patients seen in medical settings (Barker and Whitfield 1991). For example, studies have shown that approxi mately 20 to 30 percent of patients seen in primary care settings may have problems with alcohol, including alcoholism (Ry don et al. 1992; Barry and Fleming 1993). When data from hospital services are ex amined, alcoholism has been documented in as high as 42 percent of male and 35 percent of female patients (Lewis and Gor don 1983). Given that these prevalence figures are similar to those for other chronic diseases, such as hypertension and diabetes, internists should evaluate their patients for alcoholism with the same rigor that they approach these other common problems.

EVALUATING PATIENTS FOR ALCOHOLISM
Despite the high prevalence of alcoholism, internists often fail to identify it in patients, perhaps because of inadequate training in detecting the disorder, which often is asymptomatic. They also may miss alco holism in some patients because of the prevailing negative attitudes about sub stance abuse, which suggest that substance abuse is not part of the realm of the general internist and that treatment is ineffective (Barker and Whitfield 1991;Rydon et al. 1992;Hays and Spickard 1987). Thus, general internists must overcome consid erable barriers if they are to recognize alcoholism in their patients. Internists can identify alcoholism, however, when they consider incorporating the follow ing suggestions into their practices (table 1).

Patient History
When evaluating patients, the patient history is the most valuable source of information. The internist should include the following two questions as part of the history: (1) Do you ever drink alcohol? and (2) Do you have a family history of alcoholism? The first question provides an initial assessment of alcohol use and indicates whether a more detailed screen ing is necessary. An answer of "No" in the presence of alcoholrelated medical or social problems suggests the possibility of denial and a need to revisit this issue with the patient. The second question helps  determine if the patient is at increased risk for alcoholism (Barker and Whitfield 1991;Hays and Spickard 1987), because people with alcoholic relatives stand a greater chance of developing alcohol problems themselves. The internist should ask patients who do drink more detailed questions (table 2) about their drinking patterns and screen for alcoholism if necessary (discussed below). Routine alcoholuse questions help determine patients' drinking patterns, including frequency, amount, and whether they consider themselves to have had drinking problems in the past. The internist should keep in mind that alcohol use has its own social context that may vary sig nificantly among people, depending on factors such as nationality and ethnic background. Information on the frequency of drinking may help distinguish daily drinkers from binge drinkers, 2 both of whom may develop patterns associated with alcoholism. When determining alco hol intake, the internist should explore a range by asking patients about their usual 2 In this context, a binge drinker is an episodic heavy drinker who consumes several drinks on any single occasion.
number of drinks and whether they ever drink more, to identify binge drinking.

Physical Examination
Unlike a patient history, a physical ex amination is not an effective method for detecting unsuspected alcoholism; there are no diagnostic physical signs of alcohol ism, and most patients who have a history of problem drinking will have a normal physical examination. However, the exam ination is a useful tool. The presence of certain common medical conditions, such as hypertension, gastrointestinal bleeding, and chronic liver disease, which are associ ated with alcoholism, can raise a "red flag" in the mind of the internist to the possibili ty of alcohol abuse (Barnes et al. 1987). In addition, in patients with suspected or known alcoholism, the physical examina tion can reveal other alcoholrelated com plications (discussed below).

Laboratory Tests
No laboratory test effectively detects alcoholism in asymptomatic patients. In one study of hospitalized patients that compared the efficacy of the CAGE questionnaire, a wellvalidated screening instrument, with laboratory markers (see the article by Salaspuro, pp. 131-135), the CAGE test had a positive predictive value 3 of 62 percent as compared with a positive predictive value of approximately 30 percent for laboratory markers (Bush et al. 1987).
Certain laboratory abnormalities, such as elevated liver enzymes and macrocytic anemia-a condition characterized by a reduced number of red blood cells that also are enlarged-can suggest alcoholism (Barnes et al. 1987). For example, a test that measures levels of the liver enzyme gammaglutamyl transferase (GGT) is the most sensitive of the liver function tests. It indicates current alcohol intake, but test results can be affected by conditions other than alcohol use. Laboratory tests also can be helpful in evaluating patients with known or suspected alcoholism for alcohol related complications.
Based on the results of the physical examination, laboratory tests, and the patient's answers to the history questions related to alcohol use, the internist can determine whether the patient should be screened for alcoholism.

Screening Tools
Instruments such as questionnaires (e.g., the CAGE test) that screen for alcohol use disorders are among the more effective tools internists may rely on to help deter mine whether a patient has developed alcoholism (Buchsbaum et al. 1991;Cyr and Wartman 1988). Several instruments for screening alcohol use disorders have been developed and evaluated. (For a description of common screening tools and terminology, see Nilssen and Cone, It is important to remember that screening instruments for alcoholismas with other screening tools such as mammography for breast cancer-do not establish a diagnosis of alcoholism. A positive result on the CAGE test does indicate that further evaluation is needed to determine if alcoholism is present, just as a biopsy may be indicated in the case of an abnormal mammogram. Thus, patients with known or suspected alcoholism should be asked more specific questions.

Use of Other Substances
Because patients suspected of having alcohol problems also may be abusing other substances, the internist must con sider polysubstance use when evaluating patients who use alcohol. These patients should be asked about their use of tobac co, prescription drugs, and illicit drugs. Recognizing polysubstance use without asking about it may be difficult because its physical signs, if any, are similar to those of alcohol use. For example, some characteristics of alcohol addiction, in cluding tolerance, withdrawal, loss of control, and social consequences, are common to other substance addictions. However, alcohol is distinct from these other substances given the specific phar macological properties that result in a pattern of withdrawal and characteristic medical complications.

Making the Diagnosis
Having ascertained the patient's level of alcohol use employing the techniques above, the general internist can focus on making a diagnosis of alcoholism. The internist should consider the characteristic (1) Do you ever drink alcohol?
(2) Do you have a family history of alcoholism?
Ask all patients who drink alcohol: (1) Alcohol use questions When was your last drink? How often do you drink? How much do you usually drink? Do you ever drink more? Have you ever had a drinking problem?
(2) Screening questions from the CAGE test Have you ever felt you should CUT down on your drinking? Have people ANNOYED you by criticizing your drinking? Have you ever felt bad or GUILTY about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (EYE opener)?
Ask patients who do or may have problemdrinking behaviors about more specific aspects of their alcohol use: (1) Withdrawal symptoms and complications (1) Tobacco (2) Prescription drugs (3) Illicit drugs such as heroin and cocaine features of alcoholism, including the patient's inability to control alcohol in take, preoccupation with alcohol, use of alcohol despite the presence of adverse consequences, and distortions in thinking such as denial (Morse and Flavin 1992). The internist also should refer to the definitions and diagnostic criteria of alcohol abuse and alcohol dependence outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association [APA] 1994). Diagnostic criteria for alcohol abuse include (1) a pattern of pathologic alcohol use (e.g., a need for daily use to function, an inability to cut down, and binges) and (2) impair ment in social functioning due to alcohol use (e.g., employment, legal, and family problems). Diagnostic criteria for alcohol dependence include indications of alcohol abuse and of tolerance, as evidenced by increasing amounts of alcohol intake or withdrawal (APA 1994). Even with these specific criteria, the internist often must consider nonspecific symptoms (e.g., fatigue or anxiety) in the presence of a positive family history or other problems commonly thought to be alcohol related (e.g., hepatitis or pancre atitis) when diagnosing alcoholism.

COMMON COMPLICATIONS OF ALCOHOLISM
Although patients who abuse alcohol often are asymptomatic, alcohol abuse is known to result in a variety of social, behavioral, medical, and psychiatric complications that can serve as clues to the presence of problem drinking (Morse and Flavin 1992;APA 1994;Eckardt et al. 1981).

Social and Behavioral Complications
Often, internists are more aware of the most frequently described medical and psychiatric complications of alcohol abuse, such as chronic liver disease and depression, than they are of the social and behavioral complications. These prob lems, however, may be the most common presenting "symptoms" of alcohol abuse seen by the internist. Such symptoms often are revealed during a routine exami nation and can be quite diverse, including indications of family dysfunction, legal and employment problems, and frequent accidents (see the article by Soderstrom, pp. 127-130).

Medical Complications
Although many patients with alcohol problems do not have medical complica tions, some do exhibit nonspecific symp toms such as fatigue, abdominal pain, and poor nutrition, which may be caused by any of a number of alcoholrelated com plications (table 3).
Gastrointestinal Tract. Problems of the esophagus, such as chronic inflammation, malignancies, MalloryWeiss tears, 4 and esophageal varices, 5 all have been associ ated with alcohol abuse (Eckardt et al. 1981;Van Thiel et al. 1981). Presenting symptoms can include weight loss; chest pain, or "heartburn"; vomiting of blood; and difficulty in swallowing.
Alcohol abuse has been associated with gastrointestinal bleeding from peptic ulcer disease (Eckardt et al. 1981) along with nausea, vomiting, and abdominal pain.
Alcohol abuse also can lead to malnu trition due either to poor eating habits or to malabsorption of nutrients. These nutritional deficiencies can be evident in a patient with weight loss, peripheral neuropathy (due to a folate deficiency), and Wernicke's encephalopathy (due to a thiamine deficiency).
Liver. Alcohol abuse is associated with "fatty liver," which may be asymptomatic or associated with such nonspecific symp toms as abdominal discomfort or ano rexia. The period of time spent drinking required for developing fatty liver is highly variable among people. 6 Alcoholic hepatitis represents more advanced acute liver disease as evidenced by fever, nausea, vomiting, abdominal pain, and liver dysfunction (Lieber 1984). Although chronic liver dysfunction occa sionally is asymptomatic, patients with Pancreas. Among the most dramatic manifestations of alcohol abuse is acute pancreatitis, which causes intense abdom inal pain, nausea, vomiting, and fever (Eckardt et al. 1981;Van Thiel et al. 1981). Patients with recurrent pancreatitis may develop chronic pancreatitis, mani fested by chronic intractable abdominal pain and poor nutritional status from malabsorption of nutrients.
Nervous System. Alcohol can have acute and chronic toxic effects both on the central nervous system (the brain and spinal cord) and the peripheral nervous system (outside the brain and spinal cord) (Charness et al. 1989). Although acute central nervous system effects such as intoxication and withdrawal are seen commonly in emergency settings, in ternists also may see these effects when managing patients in primary care set tings. Alcohol abuse may be associated with central and peripheral nervous sys tem effects such as mild to severe cogni tive impairment, including impaired short and longterm memory and defi cient functioning in activities of daily living, such as an uncoordinated gait, which is evidence of cerebellar degenera tion (Charness et al. 1989).
Cardiovascular System. Common cardio vascular manifestations of alcohol abuse include hypertension with fatigue, palpita tions, and shortness of breath; cardiac arrhythmias (or irregularities in the heart beat, e.g., "holiday heart"); and chronic cardiomyopathy (or disease of the heart muscle) (Lang and Quinnunen 1987). Research data suggest that moderate to high levels of chronic alcohol intake are associated with hypertension and that decreased alcohol intake may lower blood pressure (Klatsky et al. 1977;Puddey et al. 1987). Despite evidence of the harmful cardiovascular effects of alcohol, other data suggest that moderate alcohol intake may have beneficial effects, such as re ducing fats found in the blood serum and thus potentially reducing cardiac risk (Gaziano et al. 1993). Any benefit, how ever, may well be outweighed by the risks of the other alcoholrelated complications previously described.

Other Medical Complications.
Cancers known to be alcohol related include those of the mouth, oropharynx, and esophagus (Lieber et al. 1979). Cancers postulated to be associated with alcohol abuse include those of the pancreas, colon, and breast, although data for these cancers have been less convincing. Alcoholrelated cirrhosis also has been associated with the develop ment of primary liver cancer, or hepatoma.
Other important medical problems seen in alcoholabusing patients result from a weakened immune system and include the infectious diseases pneumonia and tuberculosis (Adams and Jordan 1984). These diseases may be influenced by alcoholrelated factors such as poor nutrition, respiratory tract dysfunction, and the environment within which alco holics may live.

Psychiatric Complications
The general internist may see alcoholic patients who have a variety of psycholog ical symptoms or psychiatric diagnoses. Symptoms that can be strongly associated with alcoholism include fatigue, anorex ia, or mild depression; however, they often indicate conditions unrelated to alcohol problems.
It is suggested that between 30 and 50 percent of alcoholics may meet criteria for major depression (Goodwin 1992). Patients may receive a diagnosis of alco holism in addition to a diagnosis of a specific psychiatric disorder. For exam ple, anxiety disorders are common in alcoholics (Goodwin 1992). It is impor tant, therefore, that internists perform a careful psychiatric evaluation on these patients, and when appropriate, refer patients for more specialized care.

Handling Barriers to Discussion
Among the most challenging aspects of the practice of internal medicine is dis cussing a diagnosis of alcoholism with a patient (Barnes et al. 1987;Barker and Whitfield 1991;Hays and Spickard 1987). Patient attitudes toward or perceptions of alcoholism may create barriers to the discussion, which must be overcome if the patient is to get treatment. One barrier is the feeling of shame and hopelessness common in patients with alcoholism. Be cause of these feelings, it is imperative that the internist discuss the diagnosis in a sensitive and nonjudgmental fashion and be hopeful with patients, assuring them that their problem can be treated successfully.
As a step toward opening a discussion, the internist should educate patients about the effects of alcohol and the diagnosis and prognosis of alcoholism. Patients may have their own preconceived notions about the "skid row" alcoholic, another barrier to discussion, and may not under stand that there is a spectrum of disease severity. Patients may feel more comfort able discussing alcoholism as a "chronic disease" and need to learn that it is not indicative of a personality disorder or moral inadequacy.
Once patients are educated about alcoholism, they must learn to recognize that they have the disease. Physicians can use information gathered from the history, physical examination, laboratory studies, and screening tests to demonstrate that the patients' clinical problems correspond with those indicative of alcoholism. To make this point to patients, physicians may tell them how their particular social or occupational dysfunction or medical complications relate to patterns of patho logical drinking (Barnes et al. 1987). Pa tients must be left with a sense that the physician will be their advocate in help ing them deal with the psychological and medical consequences of alcoholism.
Particularly challenging may be the patients who do not accept the diagnosis, despite exhibiting major complications of alcoholism. In these situations, physicians must continue to work with patients to overcome their denial so that treatment may be attempted. Future visits to treat other medical problems may serve as opportunities for the physician to re address alcoholism by further educating patients and discussing the diagnosis.
It is important for the physician to differentiate between patients who deny that they have a problem from those who are ambivalent about the diagnosis, be cause the means for getting these patients into treatment differ. Ambivalent patients may recognize that their own situation is indicative of alcoholism but may not believe that the diagnosis represents a significant problem. In this case, motiva tion to seek treatment is as important as education about the diagnosis. Patients who develop concerns about their drink ing may wish to restrict their treatment activities to those that can be provided by their internist because of their anxiety about the potential stigmatization asso ciated with entering a formal treatment program. However, the physician must let the patient know from the beginning that more specialized treatment may be necessary eventually.

Readiness for Change
An important aspect of successful treat ment is a patient's readiness for change, which can be assessed by the physician. According to a model for change devel oped by Prochaska and DiClemente (1986), patients may be thought of as attaining various levels of willingness to change an alcohol problem. The levels range from precontemplation-when the patient has not yet thought about the need to change, to maintenance-when the patient has made a change and continues to manage the problem by sustaining a healthier lifestyle. Once physicians have determined which level a patient has reached, they may find techniques that rely on openended questions and emphat ic listening helpful in moving a patient from one level to another (Miller and Rollnick 1991). The overall goal in this process is to avoid a relapse and secure longterm maintenance of abstinence from alcohol use.

TREATING ALCOHOLISM
Through activities such as using brief officebased interventions, referring patients to treatment programs, involving the patients' families in treatment, and monitoring patients' progress (discussed below), internists may play a critical role in their patients' alcoholism treatment (table 1).

OfficeBased Interventions
A growing body of evidence suggests that officebased interventions can have a significant impact on decreasing alcohol use in patients with alcohol problems (Barnes et al. 1987;IOM 1990;Barker and Whitfield 1991;Babor et al. 1986). These brief minimal interventions typi cally include advice or counseling given in the provider's office. For example, after reviewing the patient's drinking pattern and evidence of drinkingrelated complications, the physician may advise the patient to stop drinking or reduce alcohol intake. Brief interventions may be useful for all patients with problem drinking, although many patients, espe cially those with moderate or severe disease, also may require referral to alco holism treatment.

Involving Family in Treatment
Whether a treatment strategy is office based or a patient is referred to an out side agency, it may be helpful to involve patients' families in the treatment process when possible. This is particularly impor tant given that a supportive environment is often the key to successful treatment. With the patient's consent, family mem bers should be invited to a discussion with the physician about the diagnosis and treatment plans for the patient. Physicians should be aware of the potential for con flict in this situation; however, the po tential benefits may outweigh this risk. Formal family therapy available through an alcoholism treatment center may be particularly helpful to patients whose families are supportive and want to be involved in the treatment process. Family members also may benefit from partici pating in a support group such as AlAnon.

Referring Patients for Alcoholism Treatment
In addition to officebased interventions, patients with moderate to severe alco holism often will require referral to out side services. When a referral is made, it is critical for the internist to communi cate closely with the alcoholism treat ment professionals so that comprehensive and coordinated services can be provided to patients. Selfhelp groups such as Alcoholics Anonymous (AA) can be attractive to some patients, given their accessibility and low cost (Barnes et al. 1987). In any city, there is often more than one meeting every day, and no fee is charged.
The majority of patients with alcohol related problems can be managed in outpa tient settings such as AA. Internists should be familiar with available outpatient treat ment programs that provide services such as individual and group counseling to help patients maintain abstinence.
However, patients who have failed multiple attempts at outpatient treatment may benefit from a trial of inpatient thera py. This approach may be indicated for people with a high level of alcohol depen dence or significant cooccurring medical or psychiatric disorders that would make outpatient detoxification unmanageable.

Monitoring Recovery of Patients in Treatment
Once patients have entered treatment successfully, the internist can continue to play an important role in monitoring their recovery (Barnes et al. 1987;NIAAA 1990;Barker and Whitfield 1991). The internist can be instrumental in explicitly supporting abstinence (Barnes et al. 1987;Barker and Whitfield 1991) by regularly inquiring whether the patient has attained abstinence and providing appropriate positive feedback. The internist also should continue to communicate with the patient's alcoholism treatment professionals to remain abreast of the patient's progress.
The internist's role also may include managing the patient's alcoholrelated medical problems over a number of months or years and looking for evidence of impending relapse (Barnes et al. 1987;Barker and Whitfield 1991). Accordingly, internists should be aware of the progres sion a patient's attitudes often follow. Immediately after giving up alcohol, patients may experience a significant degree of euphoria as a reaction to their newly attained abstinence. Relapse be comes more likely for patients in whom distressing psychological symptomssuch as anxiety, for which they may have been drinking alcohol originally-become exacerbated in the absence of alcohol. One indication of increased risk of re lapse is a protracted withdrawal syndrome, which can last months and cause depres sion, anxiety, and insomnia (NIAAA 1990). Reassurance from the internist is particularly important for these patients, whereas psychoactive medications (e.g., benzodiazepines) to treat chronic with drawal symptoms should be avoided be cause of the alcoholic's susceptibility to becoming addicted to such medications.
Even patients who initially avoid relapse find other pitfalls awaiting them as they try to remain abstinent. For exam ple, they may experience difficulty reestablishing the appropriate relation ships necessary to support abstinence. Recovery may require them to find jobs or change jobs and develop new friend ships with nonalcoholic people. The internist can reinforce the necessity of these changes.

SUMMARY
The diverse medical and psychological problems associated with alcoholism have a significant impact on the practice of internal medicine. Internists must ac knowledge the possible existence of alco hol as the cause of problems among their patients and should screen all patients for evidence of drinking problems. Accord ingly, they must be proficient in using specific screening and diagnostic strate gies. Initial alcoholism treatment may take place in primary care settings by internists who should foster a noncritical environment and be prepared to help patients recognize their alcoholism and begin to address it. Internists should be well versed in local treatment resources and know how to refer patients when needed. Ultimately, a primary care physi cian such as an internist may be best suited for coordinating the care of alco holic patients and should keep in close contact with both patients and treatment professionals throughout the period of alcoholism treatment. ■